Analysis Of The Relative Motion Between The Socket And Residual Limb In .
Journal of Applied Biomechanics, 2021, 37, 21-29https://doi.org/10.1123/jab.2019-0362 2021 Human Kinetics, Inc.ORIGINAL RESEARCHAnalysis of the Relative Motion Between the Socketand Residual Limb in Transtibial Amputees WhileWearing a Transverse Rotation AdapterCorey A. Pew,1 Sarah A. Roelker,2 Glenn K. Klute,3,4 and Richard R. Neptune21Montana State University; 2The University of Texas at Austin; 3University of Washington; 4Center for Limb Loss and MobilityThe coupling between the residual limb and the lower-limb prosthesis is not rigid. As a result, external loading producesmovement between the prosthesis and residual limb that can lead to undesirable soft-tissue shear stresses. As these stresses aredifficult to measure, limb loading is commonly used as a surrogate. However, the relationship between limb loading and thedisplacements responsible for those stresses remains unknown. To better understand the limb motion within the socket, aninverse kinematic analysis was performed to estimate the motion between the socket and tibia for 10 individuals with atranstibial amputation performing walking and turning activities at 3 different speeds. The authors estimated the rotationalstiffness of the limb-socket body to quantify the limb properties when coupled with the socket and highlight how this approachcould help inform prosthetic prescriptions. Results showed that peak transverse displacement had a significant, linearrelationship with peak transverse loading. Stiffness of the limb-socket body varied significantly between individuals, activities(walking and turning), and speeds. These results suggest that transverse limb loading can serve as a surrogate for residual-limbshear stress and that the setup of a prosthesis could be individually tailored using standard motion capture and inversekinematic analyses.Keywords: inverse kinematics, simulation, prosthesis, below-knee amputeeThe coupling of lower-limb prosthetic components to theindividual’s residual limb presents many challenges. Often, thehigh loads of ambulation are transmitted through the soft tissuesto the skeletal system, which can produce damaging shearstresses.1–3 Shear stress can be particularly high during turningand twisting activities as most prosthetic legs allow limitedmotion in the transverse plane,4 which requires the residuallimb to absorb the majority of the displacement. Transverserotation adapters (TRAs) have been shown to absorb some ofthis motion and reduce loading on the residual limb.5–7 The use ofa TRA has also been shown to reduce metabolic cost and stepwidth during straight-line walking,8,9 improve turning and walking over rough terrain,9 and marginally increase activity level.10In addition, our recent studies using a variable-stiffness TRAhave shown that lower adaptor stiffness values can significantlyreduce loading at the socket in the transverse plane11–14 and thatdifferent stiffness settings may be beneficial for varying activitiesand walking speeds compared with current single-stiffness TRAs.While reductions in loading are generally regarded as beneficial,there is no established practice to determine the proper stiffness ofa TRA that will provide the greatest user benefit when balancingcomfort, mobility, and user preference.14 Currently, the setup of aTRA is adjusted iteratively using the subjective experience of theprosthetist and feedback from the user. While this processPew is with the Department of Mechanical and Industrial Engineering, MontanaState University, Bozeman, MT, USA. Roelker and Neptune are with the WalkerDepartment of Mechanical Engineering, The University of Texas at Austin, Austin,TX, USA. Klute is with the Department of Mechanical Engineering, University ofWashington, Seattle, WA, USA; and the Department of Veterans Affairs, Center forLimb Loss and Mobility, Seattle, WA, USA. Pew (Corey.Pew@montana.edu) is corresponding author.generally results in an acceptable setup, a more objective methodto determine the optimal stiffness setting could increase efficiency and consistency across individuals.One main drawback of previous research aimed at characterizing the influence of a TRA on residual limb loading is thedifficulty in measuring soft-tissue shear stress directly. In general,reductions in loading should relate to reductions in displacementbetween the socket and residual limb that cause shear stress.However, no analysis has been performed to directly relate these2 quantities. Motion of the residual limb is difficult to measureexperimentally via motion capture as markers cannot be placed onthe residual limb inside of a conventional socket.15 While someexperimental methods have been developed to help estimate,visualize, and measure this movement,16–19 these methods onlyquantify motion between the socket and socket liner surface and donot quantify motion of the deeper soft tissues. This is important asshear of the skin and muscle tissues can result in deep tissue injuryin lower-limb amputees, which can also lead to muscle lesions andocclusion of blood flow.2,20 Some studies have utilized imagingtechniques such as X-ray and ultrasound to image the motion of theskeletal system relative to the socket.21–25 However, these methodsare limited to images taken during static poses, they exposeindividuals to harmful radiation, and often require the creationof custom sockets to house imaging equipment.Models of the lower limbs as mechanical systems have beendeveloped to understand how devices such as a TRA interact withthe body and aid in the design and setup of prosthetic devices.26–31These studies have generally focused on the mechanics of the footand ankle with little attention paid to the socket-residual limbinterface. Using finite element analyses, others have sought tounderstand the mechanical properties, shear stresses and strains,and displacements being experienced by the soft tissues inside of a21Unauthenticated Downloaded 05/23/22 05:40 AM UTC
22Pew et allower-limb prosthesis.2,19,32,33 However, they are limited by usingsoft tissue properties from a small number of individuals that aretaken statically instead of during dynamic gait events. While thesestudies have provided useful information about how the limb maybehave mechanically during standing and the interactions that mayoccur inside of the socket, they do not provide estimates duringambulation or the ability to easily customize that analysis for aspecific individual. This is because the specific tissue composition,the location of the bony anatomy within the residual limb, and thespecific interface between the socket and residual limb can varywidely across individuals, making it difficult to quantify the motionbetween the socket and residual limb.Methods utilizing modeling and simulation to estimate themotions between the prosthetic socket and residual limb usinginverse kinematic (IK) approaches have also been developed tohelp understand the motions of the residual limb inside of thesocket.15,34 IK methods calculate the position of individual bodiesin the model and are used to estimate the unknown motion betweenthe socket and residual limb using data from a standard motioncapture experiment. The objective of our present study was to relatethe relative rotational motion between the residual limb and socketthat causes shear stresses in the soft tissues and measured transverse plane load applied to the distal end of the socket using anIK analysis. In addition, an estimation of the physical attributes ofan individual’s residual limb and how it interacts with their socketcould provide a quantitative approach for determining an idealstiffness for a TRA. To this end, we used the measured load andestimated displacement to quantify the transverse rotational stiffness of the socket-limb body (liner, skin, and soft tissues combined) for individual subjects and activities (walking and turning)performed at different speeds, which were then used to model thelower limb of the amputee and provide an individual specific setupfor a TRA prescription. Specifically, we hypothesize that (1) thepeak transverse plane moment will have a positive, linear relationship to the peak estimated relative motion between the socket andresidual limb and (2) the transverse stiffness of the residual limbsocket body will vary based on each individual subject, activity,and speed.MethodsTen unilateral, transtibial amputees (1 female, age: mean 51 [SD17] y, mass: 84 [13] kg, height: 1.78 [0.08] m, Table 1) gave theirTable 1Demographic Data for ParticipantsAmputationSubject etiology12345678910informed consent to this protocol reviewed and approved by theVeterans Affairs Puget Sound Health Care System and the University of Washington.14 Inclusion criteria required that subjects:(1) be 18–75 years of age, (2) be a unilateral or bilateral, transtibialamputee, (3) have been fit with a prosthesis and used it for at least6 months, (4) use the prosthesis for at least 4 hours per day by selfreport, (5) are able to ambulate without the use of extremity aids,and (6) have no concurrent musculoskeletal injuries or other healthconditions that would prevent them from completing the fullprotocol by self-report. Gait kinematics and kinetics were collectedusing a 12-camera Vicon system (Vicon, Centennial, CO), 8 forceplates (AMTI, Watertown, MA), and an iPecs 6-axis load cell(College Park, Warren, MI) installed on the distal end of the socketto directly measure transverse plane loading of the residual limb(normalized by body mass). Kinetic data (force plates and iPecs)were recorded at 1200 Hz while kinematic data were recorded at120 Hz. Raw data were processed using a low-pass Butterworth filterat 25 and 6 Hz for the kinetic and kinematic data, respectively.Subjects wore an adjustable TRA during testing using 3 fixedstiffness settings (compliant: 0.25 N·m/deg, intermediate: 0.75 N·m/deg, stiff: 1.25 N·m/deg) at 3 speeds (self-selected, fast, and slow: 20% of self-selected, respectively) during 3 activities (straight-linewalking [ST], turning with the prosthesis on the inside of the turn [PI],and turning with the prosthesis on the outside of the turn [PO], 27conditions total). Straight-line, steady-state walking was performedoverground along a 10-m walkway, and turning was performed bywalking around a 1-m radius circle.14,35 Participants wore their asprescribed socket and suspension and were fit by a certified prosthetistwith the experimental TRA and a Vari-Flex Low Profile foot (Össur,Reykjavík, Iceland).Markers were placed on the subjects by the same individualsacross all subjects to improve repeatability of placement. Allsubjects were instrumented with 71 motion-tracking markers according to a modified Plug-in-Gait full-body model (Vicon).12Modification of the model included the addition of marker clusterson the thighs and upper arms and markers on the first and fifthmetatarsal heads, tibial tuberosity, fibula head, and the medialaspects of the ankle, knee, and elbow joints. Femoral condylemarkers were placed on the prosthetic socket by asking the subjectto bend their knee several times and visually aligning the markers tothe axis of knee rotation. Tibial tuberosity and fibular head markerswere placed on the outside of the socket on the affected side andmatched to their locations on the residual limb as closely aspossible by visual ial hemimeliaCancerDiabetic/vascularTraumaTime sinceamputation, y236438491121132Liner (brand, sock plies)WillowWoodÖssur IcerossWillowWoodWillowWoodÖssur IcerossÖssur IcerossÖssur IcerossWillowWoodWillowWoodÖssur IcerossAlpha, 3-plySynergyAlpha, 5-plyAlphaSportComfort, 5-plySleeve, 1-plyAlpha, 13-plyAlpha, .898.992.172.648.980.991.092.5StraightSSW, m/sTurn 04)(0.04)Abbreviation: SSW, self-selected walking speed. Note: Straight-line walking and turning SSWs reported for each individual, mean (SD).JAB Vol. 37, No. 1, 2021Unauthenticated Downloaded 05/23/22 05:40 AM UTC
Relative Socket Motion in Transtibial AmputeesA generic musculoskeletal model for the transtibial amputeeswas developed based on the work of LaPré et al.15 Briefly,the Gait2354 OpenSim model36 was modified by transectingthe affected tibia and removing all bodies and muscles distalto the transection point.15 As recommended by LaPré et al,15 themotion between the residual tibia and socket segments of themodel were restricted to 4 degrees of freedom, 3 rotationaldegrees of freedom, and 1 translational degree of freedom alongthe length of the tibia (ie, to allow pistoning). In addition, theLaPré et al15 model was further modified to include a rotationaldegree of freedom between the prosthetic socket and foot segments to accommodate the transverse plane motion of the TRA(Figure 1). In OpenSim (version 4.0),36 the model was scaledfor each individual subject by minimizing the difference betweenthe experimental location of 22 markers on the subject during astatic trial and their respective virtual locations on the model,which included the C7 spine, clavicle, left and right anteriorsuperior iliac spine, posterior superior iliac spine, lateral andmedial femoral condyles, lateral and medial malleoli, first andfifth metatarsal heads, tip of the second toe, and heel. Becausemarkers could not be placed at the effective center of rotationon the prosthetic ankle, the amputated tibia and prosthetic socketwere scaled proportionally to the intact tibia. The IK analyseswere performed via a MATLAB (MathWorks, Natick, MA)interface with OpenSim to allow batch analyses of trials fromeach subject during each activity and speed combination. Tracking markers for the IK analysis included all those from the scalingset and added the left and right acromion processes, tibialtuberosity, fibular head, and clusters of 4 markers on the thighs.The IK analyses solved a weighted least squares problem to23minimize the error between the experimental and virtual markerlocations during each activity trial. Maximum marker error duringthe IK analysis was limited to 4 cm, and any trials that were not ableto meet that specification were not used for the analysis.37The relationship between the measured peak transverse planemoment and estimated peak rotation between the socket andresidual limb was analyzed using a linear regression model withfixed effects for stiffness setting, activity, speed, and subject withan intercept through the origin. The fixed intercept at the originwas used based on the assumption that at zero load, there willbe zero deflection. A linear mixed-effects model with fixed effectsfor stiffness setting, activity, speed, and random effects for theindividuals was used to investigate relationships between the TRAstiffness setting and estimated rotation. The limb-socket bodystiffness was calculated by dividing the measured peak force atthe socket by the peak estimated motion from the IK analysis. Arepeated measures analysis of variance was used to determine iflimb-socket stiffness varied between the different individuals,activities, and speeds. If an overall difference was found, pairwisecomparisons were performed using the estimated marginal meansand Tukey method for comparing families to determine specificdifferences. Data were evaluated only during the stance phase ofeach task when the limb was loaded.3 Comparisons were made forall activities together as well as for each activity individually, withsignificant relationships indicated by P .05. The use of the iPecsload cell allowed for multiple-stance phase measurements duringeach trial (ie, multiple steady-state steps). With each of the 10subjects performing multiple trials for the varying conditions, atotal of 4060 stance phases were used for this analysis.ResultsFigure 1 — Prosthetic limb model detail. Origins are defined at theproximal end of each segment. The 4-degree-of-freedom model betweenthe socket and transected tibia allows for rotation between the tibia and socketin all 3 axes as well as translation along the y-axis (pistoning). An additionaldegree of freedom was also added to accommodate TRA rotation about they-axis. TRA indicates transverse rotation adapter.The analysis identified a positive, linear relationship between thepeak transverse plane moment and estimated relative motionbetween the socket and residual limb. Qualitatively, the patternsof the estimated rotation matched those of the measured transverseloading across the 3 activities during the stance phase (Figure 2).Significant, positive, linear relationships between the peak transverse plane moment and peak estimated relative rotation betweenthe socket and residual limb were found for all activities (walkingand turning; Figure 3; all Ps .030), with the exception of externalrotation during straight-line walking (Table 2). In addition, wefound that the linear slope differed between internal and externalrotations for all activities (P .005). The peak estimated rotationresults showed that, on average, across TRA settings, activities andspeeds of the residual limb experienced 16 (SD 13) deg of displacement relative to the socket. Straight-line walking and PIturning are both primarily composed of internal rotation with anaverage of 13 (5) deg and 29 (11) deg, respectively. The PO turninghad the largest magnitude in the external direction with 9 (4) deg ofdisplacement (Table 2). Analyzing the activities by TRA setting, thedisplacement between the socket and residual limb did generallyincrease with increased TRA stiffness (Table 3). However, significant differences were only found for external rotation between thecompliant and intermediate settings and the compliant and stiffsettings for PI and PO turning, respectively.The stiffness of the combined limb-socket body was differentbetween the individual subjects and activities in both the internaland external directions (all Ps .001; Figure 4, Table 4). Therewere no differences between the 3 walking speeds (P .286 andP .301 for internal and external rotation, respectively). However,there were differences between the fast and slow speeds duringJAB Vol. 37, No. 1, 2021Unauthenticated Downloaded 05/23/22 05:40 AM UTC
Figure 2 — Mean (bold lines) and SD (shaded regions) for the transverse plane moment measured at the bottom of the socket (left) and the estimatedrelative motion between the socket and residual limb (right) for the 3 different activities. The horizontal axes show the percent of stance from heel strike totoe-off. These data represent all tested TRA stiffness settings combined. TRA indicates transverse rotation adapter.Figure 3 — Relationship between the peak estimated relative motion between the socket and residual limb (y-axis) and the peak transverse planemoment measured at the bottom of the socket (x-axis). Lines represent the fit from linear regression models. (A) All activities combined, (B) straight-linewalking, (C) prosthesis inside turning, and (D) prosthesis outside turning.24JAB Vol. 37, No. 1, 2021Unauthenticated Downloaded 05/23/22 05:40 AM UTC
Relative Socket Motion in Transtibial Amputees25Table 2 Relationship Between the Estimated Peak Transverse Motion Between the Socket and Tibia Segment ofthe Residual Limb and the Peak TPM Measured at the Distal End of the SocketRelationship between peak relative motion and peak transverse nalSTPIPOLinear fit, 940.0470.1590.0830.078P valuelinear fitP value internalvs external .001 .001.030 .001 .001.189 .001 .001 .001.001 .001 .001 02)(0.004)(0.006)(0.002)(0.004)(0.006)Peak TPM, N·mm/kgPeak estimatedrotation, deg90 (49) 16 (15)16 (13) 6 (5)87 (28) 16 (16)13 (5) 3 (2)130 (47) 11 (10)29 (11) 2 (2)51 (21) 18 (17)4 (6) 9 (4).005.001 .001Abbreviations: PI, turning with prosthesis on the inside of the turn; PO, turning with prosthesis on the outside of the turn; ST, straight-line walking; TPM, transverse planemoment; TRA, transverse rotation adapter. Note: Linear fit gives the slope of the relationship between the estimated motion and measure moment values (mean [SE]). PeakTPM and peak estimated rotation (mean [SD]) are the average peak values across all individuals, walking speeds, and TRA settings. Significance of the linear fit as well asdifferences between internal and external rotation slopes (P .05) are shown in bold.Table 3 Estimated Peak Transverse Motion Between the Socket and Tibia Segment of the Residual Limb(Mean [SE])Peak estimated rotation by TRA settingComparison of stiffness settings, independent of walking speedEstimated transverse deflection,degActivity Direction Compliant InternalExternal12.8 (1.7) 1.7 (0.7)30.9 (3.3) 1.4 (0.4)5.3 (1.8) 6.6 (1.4)12.9 (1.7) 1.9 (0.7)31.2 (3.3) 1.6 (0.4)5.2 (1.8) 6.8 (1.4)StiffPairwise comparisons (P value)Compliant vs intermediate Compliant vs stiff Intermediate vs stiff13.0 (1.7) 1.8 (0.7)31.3 (3.3) 1.5 (0.4)5.4 (1.8) 7.1 viations: PI, turning with prosthesis on the inside of the turn; PO, turning with prosthesis on the outside of the turn; ST, straight-line walking; TRA, transverse rotationadapter. Note: Estimated deflection in degrees is given for the 3 tested TRA settings (compliant 0.25 Nm/ , intermediate: 0.75 Nm/ , and stiff: 1.25 Nm/ ) during the 3activities (ST, PI, and PO). Internal rotation was positive. Pairwise differences between TRA settings are given with significant differences (P .05) shown in bold.internal rotation for all 3 activities individually (all Ps .001) andduring external rotation for all activities combined and whilestraight-line walking (all Ps .008) (Table 5).DiscussionThe objective of this study was to relate the relative rotationalmotion between the residual limb and socket that causes shearstresses in the soft tissues with the observed transverse plane loadapplied to the distal end of the socket using an IK analysis. Inaddition, the experimentally measured load and estimated displacement were used to calculate the rotational stiffness of the combinedsocket-limb body for each individual during the different activityand speed combinations.Our first hypothesis, that the peak transverse plane moment willhave a positive, linear relationship to the estimated relative motionbetween the socket and residual limb, was supported for all activitiesindividually and combined. There was a linear relationship betweenpeak rotational loading at the distal end of the socket and peakestimated rotation between the socket and tibia of the residual limb.While significant relationships were found for each direction individually (Table 2), the estimated slopes did not always align wellwith the data (eg, external rotation, Figure 3A, 3C and 3D). Thelinear model accounts for the effects of TRA setting, activity, speed,and variability between individuals. With all the individual subjectdata being combined in Figure 3, it is difficult to distinguish trendsbased on visual inspection. The appearance of a poor fit is a result ofthe limited range of the external data alone when compared with theJAB Vol. 37, No. 1, 2021Unauthenticated Downloaded 05/23/22 05:40 AM UTC
26Pew et alFigure 4 — Limb-socket stiffness for each individual and activity; bars are mean with SE. Individuals without values for external stiffness did not haveenough data in the external direction to calculate a value. Subject identifiers correlate to subject numbers in Table 1. PI indicates prosthesis on the inside ofthe turn; PO, prosthesis on the outside of the turn.Table 4 Pairwise Comparison Results for LimbSocket Stiffness (Mean [SE]) Between the 3 ActivitiesTransverse socket-limb stiffness comparisons by activityDirection (0.20)(0.20)(0.28)PairwisecomparisonP valueST-PNST-POPI-POST-PIST-POPI-PO .0011.000 .001.987 .001 .001Abbreviations: PI, turning with prosthesis on the inside of the turn; PO, turningwith prosthesis on the outside of the turn; ST, straight-line walking. Note:Significant differences (P .05) are shown in bold.internal data, indicating that both internal and external rotationshould be combined when estimating the overall transverse planerotational stiffness of the limb. The significance found in this modelis best interpreted that a linear relationship is valid for a givenindividual under the conditions of TRA setting, activity, and speed.The variance in data highlights how responses differ across individuals, indicating the need for individual-specific TRA setup.During ST and PI activities, the limb experiences primarilyinternal rotation. The magnitudes of rotation were found to be13 (5) deg and 29 (11) deg for straight-line walking and PI turning,respectively. Previous studies have shown relative motion betweenthe socket and residual limb between 3 and 15 deg5,16 duringstraight-line walking, which is consistent with our findings. Thesestudies looked primarily at motion between the socket and liner,which suggests that during ST walking activities, the primarymotion may be between the socket and liner with less deformationof the soft tissues. When PI turning, we found that the residual limbrotation is more than double that of straight-line walking. Inaddition, even within our small sample size, the variation ofrotation during ST was large, with some individuals experiencingdeflections as high as 30 deg during straight-line walking and up to60 deg when PI turning. This suggests there may be a largemagnitude of deflection in the soft tissues of the residual limb,particularly when turning, which is known to result in deep tissueinjury.2,38 In addition to skin ailments that are frequently cited forindividuals with lower-limb amputation, increased shear stress onthe residual limb could occlude blood flow, which could furtherexacerbate symptoms of pain and discomfort and cause medicalcomplications, particularly for amputees of vascular etiology.20Results from the PO turning were less straightforward. The POturning method is similar to a cutting maneuver, but less aggressive. This exerted less pure rotation on the limb as compared withstraight-line walking and PI turning, which affects the motion ofthe residual limb seen during PO turns. For straight-line walkingand PI turns, the peak internal transverse plane moment corresponds well to the peak estimated rotations (Table 2). However, forPO turns, the limb experiences relatively high loading internally(50 [21] N·mm/kg) with minimal deflection (4 [6] deg) andrelatively low external loading ( 22 [20] N·mm/kg) for a largermagnitude of deflection ( 9 [4] deg). As compared with straightline walking and PI turning, during PO turning, the individualpushes laterally at heel strike to initiate the change in direction. Thislateral loading induces less internal rotation and includes off-axisloading, which may cause the limb to compress and exhibit greaterrotational stiffness, particularly during internal rotation (Table 4).During toe-off, the foot is used to propel the individual out of theturn and into external rotation with a reduced magnitude ofrotational stiffness. In addition, the technique used by each individual varied greatly, resulting in a high degree of variance(Figure 3D). Note the high SD for the peak internal loading(peak TPM) and peak rotation (peak estimated rotation) as compared with the mean (Table 2).In our previous work, we established that increasing the rotational stiffness of the TRA device resulted in significant increases toJAB Vol. 37, No. 1, 2021Unauthenticated Downloaded 05/23/22 05:40 AM UTC
Relative Socket Motion in Transtibial AmputeesTable 527Pairwise Comparison Results for Limb-Socket Stiffness (Mean [SE]) Between the 3 Walking SpeedsTransverse socket-limb stiffness comparisons by dStiffness, .39)(0.25)(0.25)(0.25)(0.11)(0.10)(0.10)Pairwise comparisonFast – SlowFast – SSWSlow – SSWFast – SlowFast – SSWSlow – SSWFast – SlowFast – SSWSlow – SSWFast – SlowFast – SSWSlow – SSWFast – SlowFast – SSWSlow – SSWFast – SlowFast – SSWSlow – SSWFast – SlowFast – SSWSlow – SSWFast – SlowFast – SSWSlow – SSWP value.405.914.196.008.491.143 .001.527 .001 .001.076 .001 .001.083 .001.376.809.137 .001.009.677.936.893.991Abbreviations: PI, turning with prosthesis on the inside of the turn; PO, turning with prosthesis on the outside of the turn; SSW, self-selected walking speed; ST, straight-linewalking. Note: Walking speeds are defined as SSW, slow, and fast. Significant differences (P .05) are shown in bold.limb loading.14 In the present study, we found that a significant,linear relationship does exist between limb loading and estimateddisplacement (Table 2). However, a significant relationship betweenTRA setting and displacement is generally not supported (Table 3),although there is a general trend of increased TRA stiffness resultingin increased rotation. This result is consistent with previous work.14Specifically, similar to the relationships we found between TRAsetting and limb loading, PI turning experiences the greatest magnitude of displacement overall, and straight-line walking and PI
Analysis of the Relative Motion Between the Socket and Residual Limb in Transtibial Amputees While Wearing a Transverse Rotation Adapter Corey A. Pew,1 Sarah A. Roelker,2 Glenn K. Klute,3,4 and Richard R. Neptune2 1Montana State University; 2The University of Texas at Austin; 3University of Washington; 4Center for Limb Loss and Mobility The coupling between the residual limb and the lower-limb .
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